Urinary System Dieases and Theraputics Flashcards
where are the kidneys located within the body?
dorsal cranial abdomen
which kidney is more cranial in the abdomen of domestic species?
right
where are kidneys located in relation to the peritoneum?
retroperitoneum
what info can be gained through performing an IV urogram /urography?
illustrates the structural integrity of the urinary system and can show if there are any blockages or leaks
what is involved in an IV urogram/urography?
injection of dye that is excreted by the kidneys so it shows movement through the urinary system and can illustrate any issues
what is the nephron?
filtration component of the kidney
what is the glomerulus?
capillary bed within the kidney where glomerular filtrate is formed
what processes occur within the glomerulus?
filtration of blood to form glomerular filtrate
in a healthy kidney are proteins filtered into the Bowman’s capsule by the glomerulus?
no - they remain in the blood
why is there high pressure in the glomerulus?
the capillary bed is in the middle of 2 arteries in series
what occurs in the proximal convoluted tubule of the kidney?
reabsorption of glucose, electrolyte handling (reabsorption or secretion)
what occurs in the loop of Henle?
counter current flow to enable production of concentrated urine, water reabsorption
what occurs in the distal convoluted tubule and collecting duct?
electrolyte and acid base regulation
site of ADH action and water reabsorption (fine tuning of urine conc.)
define azotemia
elevation of urea +/- creatinine in the blood stream
in health what normally happens to urine and creatinine?
excreted through the kidneys
what is uraemia?
clinical signs associated with azotemia (nausea and innappetance)
what are the clinical signs associated with azotemia?
nausea
inappetance
what is polyuria?
excessive urination
what is oliguria?
a small amount/inadequate urine production
what is anuria?
absence of urine production - life threatening
what is polydipsia?
excessive water intake
what is pyelonephritis?
bacterial kidney infection (either uni or bilateral)
what is glomerulonephritis?
inflammation of the glomeruli
what is renal insufficiency?
measurable reduction in kidney function
what is renal disease?
specific, underlying disease of the kidneys which may be acute or chronic
what is acute kidney injury?
sudden onset kidney disease
what is chronic kidney disease?
> 3 months duration of kidney disease
what is the most readily measurable sign of kidney disease?
inability to concentrate urine
what is the name of appropriate / well concentrated urine?
hypersthnuric
define hypersthenuric
appropriate / well concentrated urine
what is the urine specific gravity in dogs of hypersthenuric urine?
> 1.030
what is the urine specific gravity in cats of hypersthenuric urine?
1.035
what is submaximally concentrated urine?
urine where there has been some concentration by the kidney
what is the USG of submaximally concentrated urine in cats?
1.012 - 1.035
what is the USG of submaximally concentrated urine in dogs?
1.012 - 1.030
what is isosthenuria?
no modification of urine concentration - kidneys have done nothing to concentrate urine
what USG suggests isosthenuria in all species?
1.008-1.012
what USG suggests hyposthenuria in all species?
<1.008
what is hyposthenuria?
active dilution of urine, kidneys are actively getting rid of more water than usual
what are the 4 main methods of urine collection?
free catch
non-absorbable cat litter
catheterisation
cystocyntesis
when should a free catch urine sample be taken?
mid flow
what device can be used to aid free catch urine sampling?
uripet
what animals can be catheterised conscious?
male dogs
what animals must be anaesthetised in order to be catheterised?
cats and female dogs
what is the only sterile method of urine collection?
cystocyntesis - use of a needle directly into the bladder
what is the preferred method of urine collection?
cystocyntesis
why are all other methods of urine collection non sterile?
involve some way of bacteria / cell contamination (either from the environment or the animal itself)
catheterisation can lead to contamination with cells from the urethra and vulva/prepuce
what are the 2 methods of performing cystocentesis?
blind by palpation of bladder
ultrasound guided
what are the 5 main areas of urinalysis?
urine specific gravity (USG) dipstick microscopy cytology bacterial culture
what equipment is used to perform USG measurements?
refractometer
what can be analysed reliably on a urine dipstick?
pH glucose ketones protein blood
what can be identified in urine using microscopy?
crystals or casts
what are renal casts?
impression of the insides of renal tubules, formed from a variety of materials, e.g. protein (hyaline), cells (cellular)
what is the aim of bacterial culturing of urine?
to check for presence of bacteria by allowing them to grow
are some crystals found in healthy animals?
yes - struvite are one example
what will urine cytology look at?
cells and bacteria present
what can be identified on blood tests that would indicate urinary system problems?
urea and creatinine
where do urea and creatinine originate from?
endogenous waste products excreted by the kidneys
where does urea originate from?
protein breakdown anywhere in the body
what can falsely raise urea value on a blood test?
recent protein meal
how can falsely elevated urea be avoided?
using fasted samples
where is creatinine derived from?
breakdown of muscle creatinine
what no pathological reason may cause an apparently lowered creatinine level?
poorly muscled animal
what does azotemia indicate?
reduced glomerular filtration of blood
what are the 3 types of azotemia?
pre-renal
renal
post renal
what is pre-renal azotemia due to?
inadequate renal perfusion - kidneys are not filtering enough blood due to reduced flow
what could be a cause of pre-renal azotemia?
hypovolaemia
what is renal azotemia due to?
reduced functional mass of the kidneys due to underlying kidney disease (less blood filtered by kidney)
what is post-renal azotemia due to?
kidneys are functioning but waste products are not excreted
what are the 2 main causes of post renal azotemia?
obstruction of the urinary tract (urethral, ureteral)
rupture of the urinary tract
what can rupture of the urinary tract lead to?
uroabdomen - leads to urine being reabsorbed by peritoneaum
what test must be performed in a azotemic patient?
urinalysis
what is the body’s normal response to pre-renal azotemia?
to preserve as much water as possible and prevent further fluid loss - production of more concentrated urine
what indicates renal azotemia?
with poorly concentrated urine (less than hypersthenuria)
how can post-renal azotemia be diagnosed?
imaging
is it normal to produce dilute urine if non azotemic?
it can be
what are other findings on blood tests often seen alongside azotemia?
hyperphosphataemia
electrolyte derangements
anaemia
why may azotemia be associated with hyperphosphataemia?
reduced renal excretion so phosphate is not being excreted either
what electrolyte derangements are common as a result of kidney disease?
hypo or hyperkalaemia
why is hypokalaemia common in kidney disease?
excessive potassium loss due to kidney damage
what symptoms does hypokalaemia contribute to in dogs/cats with kidney disease?
weakness and inappetance
why can kidney disease lead to anaemia?
EPO (erythropoetin) is synthesised by the kidneys less in disease so fewer RBC are produced
RBC in uraemic patients have a reduced life span
what can radiography of the urinary tract be used to show?
size and shape of kidneys radiopaque stones radiolucent stones evaluation of ureteric course / insertion evaluation of morphology
how can radiolucent stones be shown on radiography?
with double contrast using dye and air
what can urinary tract ultrasound show?
parenchymal detail of kidney and prostate
evaluation of bladder wall morphology
evaluation of some causes of a post-renal azotemia - location of ureteric obstruction and free fluid associated with uroabdomen
why is cytology/biopsy not often used for kidneys?
due to large blood supply and potential for heavy bleeding
how can the risk of heavy bleeding following a kidney biopsy be avoided?
check animals clotting
samples taken from cortex only
what may a kidney biopsy be used to diagnose?
renal lymphoma (via FNA) glomerular disease (trucut biopsy)
how are kidney biopsies performed?
percutaneous - ultrasound guided
what is cytology / biopsy commonly used for in the prostate?
prostatic wash
suction biopsy
what is cystoscopy used for?
direct visualisation of lower urinary tract
collection of guided biopsy samples
laser lithotripsy of stones
what is acute kidney injury?
acute nephron damage / dysfunction
how do symptoms present during AKI?
very quickly, animal becomes profoundly ill due to sudden accumulation of toxins
what is chronic kidney disease?
chronic nephron loss
how do symptoms present during chronic kidney disease?
more gradual onset due to gradual decline in renal function
why are kidneys highly susceptible to toxic / ischaemic injury?
receive / require 20% of cardiac output despite being only 0.5% of body weight due to being hugely metabolically active so will be damaged by any reduction in blood flow/volume. They also produce many waste products which are toxic if not cleared
what urine output is AKI most commonly associated with?
anuria /oliguria - kidneys suddenly stop working
what urine output is AKI less commonly associated with?
polyuria
why is AKI with polyuria easy to manage?
toxins are still being removed so less damage is occuring
what are the main causes of intrinsic AKI?
toxic
ischaemic
infectious
cutaneous and renal glomerular vasculopathy (CRGV) in dogs
what can cause AKI due to toxins in dogs?
raisins/ grapes
NSAIDs - particularly human
diuretics - lead to hypovolaemia
cholecalciferol - leave mineral deposits in kidneys
what can cause AKI due to toxins in cats?
lilies ethylene glycol NSAIDs - particularly human diuretics - lead to hypovolaemia cholecalciferol - leave mineral deposits in kidneys
why do NSAIDs cause AKI?
inhibition of prostaglandins which have a role in control of renal plasma flow
what are the infectious causes of AKI?
leptospirosis (dogs)
pyelonephritis
what is AKI caused by cutaneous and renal glomerular vasculopathy (CRGV) in dogs accompanied by?
skin lesions
what is cutaneous and renal glomerular vasculopathy (CRGV) also known as?
alabama rot
what are the clinical findings of AKI?
azotemia, uraemia
hyperkalaemia (in anuric or oliguric patients)
hyper or hypoperfusion
other signs relating to intoxication
what are the signs of azotemia (uraemia)?
lethargic
depressed
inappetant
nauseous
why can cases of AKI with an/oliguria develop hyperkalaemia?
potassium is not being excreted so will build up
what can hyperkalaemia lead to?
cardiac arrhythmias / arrest
when may a patient with AKI become hyperperfused?
an/oliguria so fluid is not being lost and volume overload can occur
when may a patient with AKI become hypoperfused?
polyuric - lots of fluid loss
what signs are associated with ethylene glycol toxicity?
hypocalcaemia
tremors
why does ethylene glycol toxicity result in hypocalcaemia?
production of calcium oxalate crystals causes excessive calcium use
what additional signs may be seen with leptospirosis?
icterus - indicating liver damage
how can AKI be diagnosed through blood tests?
short clinical illness
acute azotemia with increased urea, creatinine, phosphate and K+ (if an/oliguric)
reduced K+ if polyuric
with inappropriately concentrated urine
no evidence of urinary tract obstruction or rupture
how can you tell that azotemia due to AKI is not pre - renal?
will be accompanied by inappropriately concentrated urine
how can you tell that azotemia due to AKI is not post - renal?
no evidence of urinary tract obstruction / rupture
what are the urinalysis findings associated with AKI?
submaximally concentrated urine - often isosthenuric
casts are commonly seen indicating tubular injury
calcium oxalate monohydrate crystals will indicate ethylene glycol toxicity
inflammatory cells or positive bacterial culture indicating pyelonephritis
what is indicated by the presence of casts in urine?
tubular injury
what is indicated by the presence of calcium oxalate monohydrate crystals in urine?
ethylene glycol toxicity
what is indicated by the presence of inflammatory cells or a positive bacterial culture in urine?
pyelonephritis
what type of calcium crystals are seen in healthy animals?
calcium oxalate dihydrate
how should urine output be monitored?
catheterisation ideally but can use pads and weigh (1g=1ml of urine)
what does monitoring of urine output show?
differentiation between an/oliguria and polyuria
what are the main steps involved in AKI management?
remove underlying cause
supportive management, pending renal recovery
specific treatment if available
how can removal of underlying cause of AKI be achieved?
stop known nephrotoxic drugs (even if prescribed)
proceed with gastric decontamination / absorption of substance ingested (if applicable) to prevent further uptake by the body
what is involved in the supportive management of AKI?
manage fluid balance, electrolytes, renal toxins - encouraging urination and removal of toxins
supplementary management including nutrition, nausea and pain
how can nausea be managed?
anti-emetics
what analgesia may be given to patients with AKI?
opioids NOT NSAIDs
what fluid type should be initially used in patients with AKI?
crystalliods - Hartmann’s
what should be treated first when giving IVFT to an AKI patient?
correct any hypovolaemia (pre-renal)
what IVFT bolus should be given to cats to correct hypovolaemia?
5ml/kg over 10-15 mins
what is euvolaemia?
normal circulatory or blood fluid volume in the body
once an AKI patient is euvolaemic what should be corrected?
any dehydration
how should dehydration be corrected in the euvolaemic patient?
replace over 6 hours
if an animal with AKI appears clinically euhydrated what % dehydration should be assumed?
5%
when should IVFT not be given to a patient with AKI?
if overhydrated as can lead to volume overload
what level of blood K+ is classed as hyperkalaemia?
> 6.5-7 mmol/l
what can hyperkalaemia lead to?
cardia arrhythmias and/or standstill
why may AKI lead to hyperkalaemia?
kidneys are major route of body K+ excretion
an/oliguria can cause build up of K+
describe features of an ECG of a patient with hyperkalaemia
flattened P
wide QRS
spiked T
what heart rate may hyperkalaemic patients have?
bradycardia
what is involved in the ongoing treatment of AKI?
fluid therapy
treatment of hyperkalaemia
specific therapy for cause (if available)
what is the role of IVFT in ongoing treatment of AKI?
maintain hydration and euvolaemia
replacement of ‘outs’
how is hyperkalaemia treated?
crystalliod IVFT to ensure renal perfusion
calcium gluconate
glucose
insulin
what is the role of calcium gluconate in the treatment of hyperkalaemia?
stabilises the myocardiocytes to make them less prone to arrhythmias
why are glucose and insulin administered to hyperkalaemic patients?
glucose stimulates insulin release which will stimulate uptake of glucose and potassium alongside - reduces K+ within blood
what is the specific therapy for ethylene glycol toxicity?
ethanol to reverse crystal formation
what is the specific therapy for Leptospirosis and pyelonephritis?
antibiotics
what are the key areas of nursing care for the patient with AKI?
ensure euhydrated, avoid overhydration ensure renal prefusion manage inappetance and nausea analgesia provide nutrition
how can hydration levels be monitored?
weigh patient to ensure body weight is maintained
what value should systolic BP be to ensure adequate renal perfusion?
120-150 mmHg
what is the minimum value of systolic BP to ensure adequate renal perfusion?
> 80mmHg
how can inappetance and nausea be managed?
maropitant - anti emetic
how may nutrition be provided to AKI patients?
orally or assisted
what must be done if feeding liquid food to a patient on IVFT?
it should be incorporated into fluid therapy calculation
what should be done if kidneys fail to respond to initial supportive therapies?
trial diuretic to stimulate urination
what does of diuretic should be given to see if patient can be encouraged to urinate?
2mg/ml frusemide ONCE
what is indicated by persistent anuria (+/- volume overload and +/- unmanageable hyperkalaemia)?
renal replacement (dialysis) or euthanasia
what clinical findings in an AKI patient would indicate dialysis or euthanasia?
persistent anuria -
+/- volume overload and +/- unmanageable hyperkalaemia
what is the survival rate for AKI in dogs?
34-59%
what is the survival rate for AKI in cats?
27-42%
why do patients presenting with polyuria alongside AKI have a better prognosis than those presenting with an/oliguria?
they are able to flush toxins from their body and so there is less damage
what do ~50% of AKI sufferers have long term?
CKD - chronic kidney damage
what is the most common kidney disease in cats and dogs?
chronic kidney disease
in what species is chronic kidney disease the most common?
cats
in what age group is CKD most commonly diagnosed?
older patients
define chronic kidney disease
functional and/or structural kidney disease of >3 months duration
can CKD be reversed?
no - irreversible and progressive
is the onset of CKD acute or gradual?
gradual
what is the management of CKD aimed at?
protecting remaining nephrons and managing clinical consequences
what is the aim of protecting the remaining nephrons of animals with CKD?
reducing progression of the disease
what are the 6 main causes of CKD?
chronic interstitial nephritis glomerulonephropathy undiagnosed / untreated infections chronic obstructive disease congenital issues neoplastic
what causes chronic interstitial nephritis?
often unknown, it is the end of many pathological processes
what is chronic interstitial nephritis?
chronic inflammation within the kidney
what congenital diseases can lead to CKD?
poly-cystic kidney disease and renal displasia (dogs - cysts replace functional renal tissue)
what are the findings within an animals history that will suggest CKD?
subtle or non-specific initially in some patients PUPD weight loss lethargy weakness inappetance
what GI signs may be seen in an animal with CKD?
vomiting diarrhoea haematemesis melaena constipation second to dehydration in cats
what signs associated with hypertension may be seen in an animal with CKD?
blindness
neurological
what findings on a clinical exam suggest CKD?
catabolic state - reduced body (muscle) condition typically dehydrated weakness uraemic ulcers/ uraemic halitosis hypertensive retinopathy
why are patients with CKD typically dehydrated?
uncontrolled polyuria - kidneys are unable to concentrate urine
may also be v+/d+
what causes weakness in the patient with CKD?
polyuria and associated excretion of K+
what can excessive loss of K+ in the CKD patient lead to?
neck ventroflexion
hypokalaemic myopathy
what causes uraemic ulcers and uraemic halitosis?
increased urea present in saliva - this is converted to ammonia by bacteria in the mouth
what will kidneys feel like on palpation in a patient with CKD?
small and irregular
what is rubber jaw?
soft bone of jaw seen in young animals with CKD
what are the target organs of hypertension?
eyes (ocular)
renal
cardiac
neurological
what is hypertensive retinopathy?
renal oedema and hemorrhages due to the effects of hypertension on the capillaries there
what can hypertensive retinopathy lead to?
acute blindness
what are target organs?
organs within the body that are particularly susceptible to damage in the small blood vessels within them due to hypertension
How can CKD lead to worsening kidney function due to its hypertensive effects?
kidney disease causes increased blood pressure which in turn damages kidneys causing further BP increase
what is an additional complication of systemic hypertension outside of the target organs?
epistaxis
what is considered normal systolic blood pressure?
120-140 mmHg
what is normal systolic BP for sighthounds/deerhounds in hospital settings?
10-20 mmHg higher than others
why do sighthounds/deerhounds have a recognised higher systolic BP than other animals?
clear predisposition to in-hospital situational hypertension
what would a systolic BP of <140mmHg be described as?
normotensive
what systolic BP is considered hypertensive?
160-179 mmHg
what is the risk of organ damage once the systolic BP is deemed hypertensive?
moderate
at what point is treatment for hypertension warranted?
> 160 mmHg
what is the ideal method of BP measurement?
direct arterial line
how many blood pressure readings hsould be taken?
5-7 consistent readings
what blood pressure readings should be discounted?
first reading and those before the plateau of meaurement
when should a second set of blood pressure readings be taken?
2 hours later
what is the correct BP cuff width if using indirect measuring techniques?
30-40% circumference of limb/tail
what must be demonstrated to diagnose CKD?
renal azotemia
what is diagnostic for CKD?
inappropriately concentrated urine
with azotemia
what is the name of the new blood test used for diagnosis of CKD?
symmetric dimethylarginine (SDMA)
how does the SDMA blood test for CKD work?
approximated GFR
what other laboratory findings may be seen alongside azotemia in a CKD patient?
anaemia
increased phosphate
reduced K+
what blood pressure findings would suggest CKD?
hypertension
why may imaging be performed in a CKD patient?
to rule out any other cause of issues that may be treatable/ require different treatment
what is involved in the initial management of CKD cases?
discontinue nephrotoxic drugs
find and treat any underlying correctable cause
correct and maintain fluid balance
what may be an underlying correctable cause of CKD?
hypertension
urinary tract infection (pyelonephritis)
ureteroliths
how can fluid balance of a CKD patient be managed?
encourage oral intake of water
give wet/soaked food
SQ fluids (owner or vet administered)
oesophageal tube
how can oral water intake be encouraged?
different water stations in different places
different types of bowls
ensure water in bowl is high enough so cat doesn’t have to move eyes below level of bowl to drink
how can progression of CKD be delayed?
renal diet - improves survival
control - hypertension, proteinuria, hyperphosphataemia and hyperkalaemia
avoid further kidney insult
how can further kidney insult be avoided?
prevention of secondary infections
careful/no use of NSAIDs
what is the aim of a renal diet?
maximise quality/longevity of life
limit clinical manifestations of disease
slow progression
how should cats eating/weight be managed to ensure they are receiving proper nutrition to manage CKD?
calculate and feed RER
weigh food eaten and any left to calculate deficit to animals intake
monitor bodyweight and condition (BCS and weighing)
adjust intake based on any changes
what must be avoided in a renal diet?
protein calorie malnutrition - ensure animal eats sufficient calories
avoid food aversion
how can food aversion be avoided?
feed new diet at home not in hospital
what is the purpose of renal diets?
minimise uraemic episodes (nausea/sickness)
minimise mortality
prolong survival
what substances are restricted within renal diets?
protein
phosphorus
sodium
why are protein, phosphorus and sodium restricted in renal diets?
limit the accumulation of uraemic toxins
what are renal diets supplemented with?
omega 3 - polyunsaturated fatty acids antioxidants B vitamins K+ (cats) soluble fibre
why must cats not be syringe fed?
risk of food aversion
what should you do if a CKD patient is unwilling to eat?
ensure euhydrated, normokalaemic
offer according to animal preferances (environmental and dietary)
potentially give anitemetic if nauseous
what can be done if a CKD patient will not eat after if is offered food it likes within its preferred environment and nausea/dehydration/hypokalaemia are ruled out?
try appetite stimulant
when may a naso-oesophageal tube be an option for CKD patients?
if they haven’t eaten for a few days as a short term solution
what is additional management of CKD determined by?
IRIS guidelines
what does IRIS stand for?
international renal interest guidelines
what may be given to a patient who is hyperphosphataemic?
phosphate binders
what do phosphate binders do?
prevent absorption of phosphate from food to bring blood level down
what can be given to a hypokalaemic CKD patient?
potassium supplementation at home (orally)
how is systemic hypertension managed in cats?
amlodipine
how is systemic hypertension managed in dogs?
angiotensin converting enzyme inhibitor (ACEi)
how can progress of CKD patients be monitored?
nurse clinics
how frequently should CKD cases be seen in a nurse clinic?
every 3 months if all is well
what should be assessed in CKD nurse clinics?
appetite demenor weight BP urinalysis specific biochem (fasted sample) PCV
what biochemistry is needed to assess progress of CKD patient?
urea creatinine phosphorus Ca2+ Na+ K+
what does PCV of a CKD patient test for?
anaeamia
what does prognosis for CKD depend on?
IRIS stage
what should be done before a prognosis is given?
address reversible component - if any
how well do cats cope with CKD?
well - can often live years
how do dogs cope with CKD?
those presenting with significant clinical signs often do poorly (weeks to months)
what is nephrotic syndrome a complication of?
glomerular disease
what does glomerular disease cause?
protein loosing nephropathy
how does glomerular disease cause protein losing nephropathy?
glomerulus becomes leaky, proteins are lost into the nephron and then out through the urine
what is the result of protein losing nephropathy?
renal albumin loss leading to hypoalbuminaemia
what can hypoalbuminaemia caused by protein losing nephropathy lead to?
reduction in oncotic pressure leading to effusions and oedema as fluid is able to seep out of blood vessels
how is nephrotic syndrome managed?
as for CKD
ACEi to reduce proteinuria
why are ACEi given to animals suffering with nephrotic syndrome?
affects BP within glomerulus meaning that less albumin is forced into nephron and then lost in urine
what is the role of omega 3 PUFA in the patient with nephrotic syndrome?
renoprotective
why is aspirin/Clopidogrel given to patients with nephrotic syndrome?
reduce risk of thrombembolytic disease due to low albumin
where are surgical diseases of the urinary tract most commonly encountered?
lower urinary tract rather than kidneys/ureters
what ensures that the correct surgical approach is taken when treating disease?
adequate investigations, history taking and clear surgical plan
what questions should be asked of an owner when presented with a potential urinary tract surgical case?
continent?
normal urine voiding?
is the animal urinating in the house / overnight?
does the animal strain to urinate unproductively?
does the animal strain to produce small amounts of urine or cry when urinating?
does the urine smell?
haematuria?
polydipsia?
is the animal neutered?
what is involved in the initial investigation of a potential surgical urinary case?
bloods
urinalysis
radiography
ultrasonography
what will be assessed on bloods taken for initial investigation of a potential surgical urinary case?
haematology - anaemia
biochemistry - markers for kidney function (e.g. urea, creatinine, K+)
during urinary tract surgery what is a potential infection source?
incision into urinary tract is a potential source of wound contamination / infection
what should be done before urinary tract surgery to reduce infection risk?
use antibiotic cover, particularly in presence of known UTI
how would you know a patient has a UTI?
pre-op culture of urine
how can the spillage of urine from the bladder be avoided during surgery?
laparotomy swabs soaked in saline packed around bladder before any incision is made
what equipment may be useful intra-operatively to contain any urine produced?
urethral catheters
what may need to be provided to the patient after urinary surgery to aid bladder drainage?
urethral catheter or cystotomy tube
what are the main surgical instruments required for urinary system surgery?
fine instruments and suture material abdominal retractors stay sutures or small retractors for bladder tubes for cystotomy urethral catheters suction spoons magnification (Loupes or microscope) sterile cotton buds
what tubes are used for cystotomy?
foley
mushroom tip
what are spoons used for during urinary tract surgery?
gentle removal of stones
what are the main surgical diseases of the kidney?
neoplasia
trauma
renoliths (renal stones)
secondary to ureteric disease
what is the most common renal tumor in dogs?
carcinomas
what are the clinical signs of renal neoplasia?
haematuria palpable abdominal mass vague signs (lethargy / inappetant)
what is present in half of dogs with kidney neoplasia?
pulmonary metastatis
when is surgery to resolve renal neoplasia not indicated?
patients with pulmonary metastasis or bilateral neoplasia
what is the most common renal tumor in cats?
lymphoma
how can renal lymphoma in cats be treated?
chemotherapy
what may cause renal trauma?
RTA or bite injury
what is a nephrectomy?
removal of kidney
what can indicate need for a nephrectomy?
uncontrolled haemorrhage as a result of renal trauma
in what animals are renal stones often seen?
in animals with concurrent chronic renal failure
when is surgery indicated for renal stones?
only if there is a blockage
how can most renal stones be dissolved?
diet
antibiotic therapy
what causes uroliths?
supersaturation of minerals within the urinary tract
what is a nephrotomy?
incision through the body of the kidney
why is there a risk of short term renal function reduction in nephrotomy patients?
placing of ‘rummel’ tourniquet around renal vessels during surgery which temporarily occludes blood flow. this reduces RPF and so kidney function may suffer
what should be closely monitored after nephrotomy?
renal function and urine output
why is a ‘rummel’ tourniquet placed around renal vessels during nephrotomy?
reduces risk of bleeding as kidneys are highly vascular
when is subcutaneous ureteral bypass usually required?
in patients with a blocked ureter, potentially due to calcium oxalate stones which cannot be medically dissolved
what uroliths cannot be medically dissolved?
calcium oxalate stones
what is a subcutaneous ureteral bypass formed from?
tubing placed within the kidney and connected to the bladder via a port located under the skin, essentially provides a new ureter
what does the port of a subcutaneous ureteral bypass allow to happen?
urinary samples are taken and tubes can be flushed to remove any further stones
when are ureters at particular risk of trauma?
during spaying
what are viable treatment options if only one ureter is damaged during spaying?
removal of the kidney/ureter
if possible the ureter can be cut upstream of traumatised area and re-impanted
how can ureteral obstruction be managed?
nephrectomy and removal of stones
ureterotomy and removal of stones
by-passing of the stone with intra-ureteral stent
what is nephrectomy?
removal of the kidney
what are the indications for nephrectomy?
renal neoplasia renal trauma chronic pyelonephritus idiopathic haematuria uretral abnormalities
what must the patient have in order to be a viable candidate for nephrectomy?
must have a normal functioning contralateral kidney
where is the incision made to perform nephrectomy?
midline laperotomy
how is nephrectomy performed?
kidney is isolated and freed from the peritoneum
renal artery and vein are ligated
the ureter is ligated and transected adjacent to the bladder
why should a nephrectomy patient be blood typed pre-op?
as there is potential for severe haemorrhage
what are the surgical diseases of the ureters?
ureters at risk of trauma during spaying
occasional stones ‘uroliths’ (cats and rabbits)
ureteral ectopia
what is ureteral ectopia?
congenital anomaly in dogs (most common in females) resulting in ureters opening into urethra (not bladder) - most cases are bilateral and intramural
what is the surgery used to treat ureteral ectopia known as?
neoureterostomy
how is a neoureterostomy performed?
incision is made through the bladder and uretal mucosa into the lumen of the ectopic ureter close to it’s entry in to the bladder wall
the ureteral and bladder mucosa are sutured together to create a new stoma
what must be closely monitored for in ureteral ectopia?
stranguria - inability to pass urine
what is the outcome of 50% of neoureterostomy surgeries?
50% of animals remain incontinent due to congenital urethral sphincter mechanism incompetance
what are the main surgical diseases of the bladder?
uroliths
neoplasia
trauma
what is the most common bladder stone type in the UK?
struvite
what uroliths are amenable to medical dissolution?
struvite and urate
in what dog breed are urate uroliths common?
dalamations
how are all other uroliths (not amenable to medical dissolution/causing obstruction) removed?
cystotomy
what can prevent recurrence of uroliths?
prescription diets
how do patients with bladder uroliths present?
haematuria
increased frequency or urgency to urinate
complete obstruction (emergancy)
in what animals is bladder neoplasia not uncommon?
elderly animals
how do patients with bladder neoplasia present?
haematuria
increased frequency / urgency to urinate
obstruction
what do symptoms of bladder neoplasia depend on?
location
can bladder neoplasia be excised?
not if it affects the bladder trigone/neck as many do
is bladder neoplasia malignant?
mostly, yes
what may be done to aid palliative care of bladder neoplasia?
partial cystectomy
what can blunt abdominal trauma cause?
bladder rupture
what is a consequence of bladder trauma?
uroabdomen
post renal failure
what should be done before surgical repair of bladder trauma?
IVFT
what may aid bladder trauma healing after repair?
indwelling catheter
when is cystotomy indicated?
removal of bladder stones
where is the incision for cystotomy made?
caudal midline laperotomy
how is cystotomy to remove bladder stones preformed?
caudal midline laparotomy
exteriorise bladder and isolate with swabs (wet)
incision in ventral midline of bladder
all stones carefully removed
why should a uretheral catheter be placed prior to cystotomy?
to flush urethra and bladder neck to remove any stones
what equipment is useful during cystotomy for the removal of bladder stones?
urethral catheters
Volkmann spoon / sterile teaspoon
what should happen to stones removed from the bladder?
submitted for lab analysis for composition and culture and sensitivity
what should be observed post operatively in a cystotomy patient?
absence of urination or abdominal distention
abdomen should be ultrasound scanned if patient is on IVFT and not urinating
when may urinary catheter placement be indicated after cystotomy surgery?
if bladder is very traumatised
what must be ensured about patient care after cystotomy surgery?
they are given plenty of opportunities to urinate
what are the main urethral diseases?
urolithiasis incontinence feline lower urinary tract disease (FLUTD) trauma neoplasia
what are the most common urethral stones in the UK?
struvite
what may cause struvite crystals to form?
UTI
what can urethral stones cause?
urethral obstruction
why are urethral obstructions more common in males?
due to their anatomy (curve in urethra)
what can urethral blockage lead to?
post renal azotemia and shock
how should a patient with urethral obstruction be treated?
restore circulating volume
reduce hyperkalaemia
relieve obstruction
what should be avoided before the urethral obstruction patient is stabilised?
anaesthesia
what should be looked for on the ECG of patients with urethral obstruction?
spiked T waves (hyperkalaemia)
how can the urethral obstruction be relieved?
empty bladder by cystocentesis
catheterise urethra
once flushed into bladder remove stones by cystotomy
what can be done if urethral catheterisation and flushing has not moved stone into bladder?
retrograde flushing attempted under GA with sterile saline
what happens if the bladder is allowed to become distended again when there is urethral obstruction?
can lead to urine leakage into the abdomen
what are the two main causes of incontinence?
congenital
aquired
how may incontinence be acquired?
age
surgical complications
in what sex is incontinence more common?
females - due to anatomy
in what species is incontinence rare?
cat
should incontinence be investigated?
yes
what is USMI?
urethral sphincter mechanism incontinence
what may cause USMI?
breed predisposition (old english sheepdog)
obesity
neutering
tail docking if nerves are interfered with
what is the most common type of USMI?
spay bitch incontinence, intrapelvic bladder
how are most cases of USMI managed?
medically with oestrogen or phenylpropanolamine
how may non-responsive cases of USMI be treated surgically?
colposuspension
urethroplexy
hydraulic artificial urethral spincters
what is FLUTD?
feline lower urinary tract disease
what is FLUTD secondary to?
some kind of bladder disease
what does FLUTD lead to in some male cats?
urethral obstruction
when does FLUTD become a surgical disease?
when males suffer repeated episodes of urethral obstruction
how can FLUTD often be managed?
medically to avoid surgery
what type of cats are predisposed to FLUTD?
middle aged
obese
dry diet
neutered
what bladder disease may FLUTD be secondary to?
neoplasia
urethral spasming
infection
feline idiopathic cystitus
is urethral neoplasia a common cause of urethral obstruction?
no
in what animals may urethral neoplasia be an issue?
elderly bitches
what is the most common form of urethral neoplasia?
transitional cell carcinoma
can urethral neoplasia usually be excised?
no - often recognised too late
what can be done to provide palliation to urethral neoplasia cases that cannot urinate?
by-passing urethra
what are two methods used to bypass the urethra?
urethral stents
tube cystotomy
what is urethrotomy?
incision into the urethra
what is urethrotomy used for?
last resort for stones that cannot be flushed back up into the bladder for removal
what is urethrostomy?
creation of a new, permanent opening
what is urethrostomy used for?
last resort for recurrent obstruction, severe trauma or stricture
where must a urethrostomy be made?
‘upstream’ from the diseased urethra
what technique can be used to confirm where urethrostomy should be placed?
retrograde urethrogram
what urethrostomy is most often performed in cats?
perineal or occasionally pre pubic
what type of urethrostomy is most often performed in the dog?
scrotal or occasionally perinial
what is tube cystotomy used for?
urethral diversion technique
when is tube cystotomy indicated?
diverting urine away from urethral surgical sites
palliation of urinary obstruction due to neoplasia and detrusor atony
what is detrusor atony?
A distended flaccid bladder that is easily expressed
how is tube cystotomy performed?
purse string suture is placed in the bladder and a foley or mushroom tip catheter is placed through a stab incision in the middle of the suture
the suture is tightened
the catheter is passed through an incision in the lateral abdominal wall and a cystopexy is performed
catheter is sutured to the skin via a chinese finger trap suture
for how long following a tube cystotomy must the tube be kept in place?
7 days
what is a side effect of tube cystotomy?
often lots of UTIs - no treatment unless clinical signs
in what animals is a urethrostomy performed?
usually males
what must be placed prior to urethrostomy?
urinary catheter
what equipment is required for urethrostomy?
fine instruments
fine non-absorbable suture
illumination
what happens during urethrostomy?
urethra is redirected out through a new hole in the skin
what are complications associated with urethrostomy surgery?
heavy bleeding
stricture
cystitus
what is crucial about post op care after urethral surgery?
absolute prevention of patient interference
what is commonly see after urethral surgery?
haematuria and bleeding from site
observe for dysuria
what is a key concern following urethral surgery in cats?
care with litter - use shredded newspaper
what may be required to safely remove sutures post urethral surgery?
GA/sedation
what key parameters should be monitored following urethral surgery?
urine output
BP
pain score
where is the prostate located?
surrounds male urethra
is prostatic disease seen in cats?
rare
what are the possible causes of prostatic disease in cats?
benign hyperplasia prostatitis abscessation cysts neoplasia
what is benign prostatic hyperplasia (BPH)?
non-cancerous enlargement of the prostate
what does BPH cause?
dysuria or dyschezia
what is dyschezia?
difficulty defecating
in what animals is BPH often seen?
older entire males
how is BPH managed?
medical management with anti-androgens (e.g Tardak
what is the preferred definitive treatment for BPH?
castration
what is prostatitis?
inflammation of prostate gland
what causes prostatitis?
bacterial infection, usually alongside BPH
what animals is prostatitis seen in?
entire males
what are the symptoms of prostatitis?
dysuria
pyrexia
purulent penile discharge
how is prostatitis managed?
antibiotics
Tardak
casteration
when are prostatic abscesses seen?
alongside prostatitis
in what animals are prostatic abscesses seen?
entire males
what are the signs of prostatic abscess?
variable systemic signs (male pyometra)
dysuria
dyschezia
what is the treatment of prostatic abscess?
omentalisation following de-roofing and flushing of abscess
castration
what is omentalisation?
the placement of omentum around organs or within cavities to improve vascularization or drainage
when is rapid surgical intervention required with prostatic abscesses?
if it has burst with signs of septic peritonitus
what additional care will be needed during surgery if prostatic abscess has burst?
antibiotics
flush abdomen
what causes prostatic cysts?
ducts become blocked and fluid builds up leading to cyst
in what animals are prostatic cysts seen?
entire males often with BPH
how are prostatic cysts treated?
de-roof
omentalisation
castration
what can prostatic cysts occasionally be caused by?
prostatic neoplasia - biopsy sent from de-roofing
what animals is prostatic neoplasia seen in?
elderly male dogs - more common in castrated
is prostatic neoplasia painful?
yes
is the prognosis of prostatic neoplasia usually good?
no - usually skeletal metasitis
how may palliative care be given to prostatic neoplasia patients?
urethral stents to aid urination if a clinical sign is inability to urinate
why is prostatectomy not often performed?
complex
often causes incontinence
what is lower urinary tract disease?
diseases of the bladder and urethra
what is cystitis?
bladder inflammation
what are the symptoms of cystitis/ LUTD?
dysuria stranguria vocalisation licking prepuce inappetance lethargy haematuria pollakiuria periuria
what is stranguria?
straining to urinate - may be reported as consitpation
what is pollakiuria?
increased frequency of urination
what is periuria?
voiding in inappropriate places due to pain association formed with normal site
do clinical signs of LUT differ depending on aetiology?
no - reflect the pathology / inflammation which accompanies
what is the most common cause of cystitis in cats?
feline idiopathic cystitis
what is the most common cause of cystitis in female dogs?
bacterial urinary tract infection
what are the main causes of cystitis in both cats and dogs?
urolithiasis
neoplasia - especially in dogs
drug induced (some chemotherapy drugs)
implants or indwelling devices
what is the most crucial question when triaging a patient with clinical signs of LUT disease?
as they still able to pass urine
when is urinary obstruction possible?
with any LUT disease
when is LUT disease an emergency?
if there is any evidence of inability to pass urine
what is a urolith?
urinary stone - organised crystal aggregates of minerals in small amounts of organic matrix
when are uroliths visible?
they are macroscopic - visible with the naked eye
what are crystals?
microscopic mineral precipitate
how can you ensure that crystals are truly found in urine and not artefact?
ensure urine is fresh and at room temperature
what is crystalluria?
crystals in the urine
does crystalluria and uroliths occur at the same time?
can do or occur seperately
are crystals and uroliths formed of the same constituents?
not necessarily - may have been formed at different times in different urine pH
what are the 3 main types of urinary stones and crystals?
struvite
calcium oxalate
urate
identify this urolith and crystal
struvite
identify this urolith and crystal
calcium oxalate
identify this urolith and crystal
urate
how are crystals formed?
urine is saturated with compounds
increased saturation leads to increased risk of precipitation of crystals as the compound can no longer be held in solution
crystals are formed
how are uroliths formed from crystals?
further supersaturation of crystals and then growth / aggregation of many crystals
why should water intake be encouraged?
the more dilute the urine, the less the risk of crystal and stone formation
does crystalluria require treatment?
mostly normal, asymptomatic and does not need treatment
some crystals are abnormal and require further investigation
what crystal types will require further investigation?
urate
what types of uroliths need treatment?
symptomatic
what are nephroliths?
kidney stones
what are the signs of nephroliths?
abdominal pain (leading to anorexia, inappetance, lethargy)
haematuria
pyelonephritis
what can ureteroliths cause?
may lead to ureteric obstruction and post renal azotemia
what are the upper urinary uroliths?
nephroliths
ureteroliths
in what species are upper urinary uroliths more common?
cats
in what species are lower urinary uroliths more common?
dogs
what are the main signs of urethroliths?
unproductive / minimally productive urination
what are cystoliths?
bladder stones
what are the signs of cystoliths?
pollakuria
stranguria
dysuria
haematuria
what may uroliths predispose?
UTI
why is identification of urolith type important?
changes management requirement
how will urolith type affect management requirement?
some can be dissolved
some need surgical removal, intervention or bypass
some will ave associated infections that need treating
what diagnostic tool can aid ‘guessing’ stone type?
radiolucency/opacity
can presence of crystals predict stone type?
no
what is the only definitive way to identify stone type?
analysis of stone
how may stones be dissolved?
diet or medication
how large do uroliths need to be to be visualised on radiographs?
> 2-3mm
what type of uroliths will be shown by plain radiographs?
radiopaque
what type of uroliths will be shown by contrast/double contrast radiographs?
radiolucent
what is the main feature of urolith treatment and management?
encourage water intake
why is high water intake so crucial with urolith management?
if urine is dilute, supersaturation, and so crystal/stone formation, cannot occur
how can water intake be encouraged?
plentiful water
wet diet +/- add water to diet
what USG should be aimed for in animals with uroliths?
cats: 1.030
dogs: 1.020
why should voiding of urine be encouraged?
to avoid urine sitting in the bladder for too long
what is a risk factor for urolith formation?
obesity
what animals are dissolution diets not suitable for?
growing or lactating animals
long term use in any animals
can some dissolution diets tackle more than one stone type?
yes - may aim to make urine pH neutral and so unsuitable for alkaline and acidic stones
how do dissolution diets work?
don’t contain constituents of stone that needs breaking down which prevents further formation and allows breakdown by urine
what are the main nursing considerations associated with a patient with urolithiasis?
observe and monitor patient for anuria / stranguria - re-obstruction possible at any time
maintain hydration and urine output
manage urinary catheter
analgesia requirements
what is the aetiology of feline idiopathic cystitis?
common with unknown cause
what is the signalment (common characteristics) of feline idiopathic cystitis?
young to middle aged (2-7) overweight inactive indoor - litter tray user multi-animal household nervous disposition dry diet stressors autumn/winter
what makes a cat susceptible to feline idiopathic cystitis?
neuroendocrine modulation
GAG layer hyperfunction
what is neuroendocrine modulation?
adjusted sensory nerve function
abnormalities of the CNS stress response
- when compared to normal cats
what does environmental stress manifest as in susceptible cats?
FLUTD
what is GAG layer hypofunction?
underfunction of proteins in lining of bladder leaving it more susceptible to irritation / inflammation
what must be ruled out before FIC can be confirmed?
all other potential causes of cystitis as they present the same
what tests are involved in diagnosing FIC?
urinalysis
radiographs
ultrasonography
if nothing found - FIC
what can be excluded by urinalysis?
UTI - rare
what can be excluded by radiography (plain, contrast and double contrast)?
uroliths
masses
contrast useful for stricture assesment
what can ultrasound show about the urinary tract?
structural architecture / evaluation of upper urinary tract
what are the 2 presentations of FIC?
non - obstructed
obstructed
what are the signs of non - obstructed FIC?
signs of LUTD pollakiuria stranguria dysuria haematuria still able to void urine
how long may non - obstructed FIC last?
self - limiting so may well last a few days and then go away
does FIC often reoccur?
yes
obstructed recurs in 40% of patients within 6-12 months
what caused obstructed FIC?
urethral spasm or plug
what are the signs of obstructed FIC?
unproductive attempts to urinate
in what animals is obstructive FIC more common?
males - rarely / never in females
what presentation of FIC is an emergency?
obstructed
what is the consequence of urinary obstruction?
back pressure on kidneys as no voiding
kidneys unable to filter blood leading to post-renal azotemia and then hyperkalaemia (and associated bradyarrhythmias)
how may cats with FIC seem in terms of mentation?
painful
agitated or depressed
what must be done to the obstructed FIC cat before they are anaesthetised for catheterisation?
stabilised - resolve hyperkalaemia and azotemia
what may owners report that can indicate urinary obstruction?
constipation - as urination and defication can appear the same
urinary catheter RCards if none on urinary catheter lecture
e.g. equipment and assisting with placement
what are the key management considerations for indwelling urinary catheters?
closed, clean system wear gloves when handling keep bag off floor keep connections clean change bag daily avoid antibiotics tape collection system to tail while tail is raised to avoid pulling use buster collar
what should be monitored post-catheterisation?
urine output
hydration / volaemic status
electrolytes
urine sediment / cytology
what is commonly seen post relief of obstruction that may contribute to hypokalaemia?
post obstruction diuresis - kidney may be damaged so not concentrating urine
what is urine sediment / cytology examined for?
shows presence of infection
how is UOP calculated?
weight of bag now - weigh of bag 4hrs ago = UOP for past 4 hours
divide by 4 to get UOP for 1hr
then divide by patient weight (kg) to calculate UOP (ml/kg/hr)
what is the main medical management of FIC in non-obstructed / post - obstructed cats?
analgesia
opioids - buprenorphine
NSAIDs - only once normovolaemic, azotemia gone and euhydrated
gabapentin in severely affected cases
how can environmental modification help long term management of FIC?
alleviate predisposing stressor - remove if known
address negative cat-cat interactions
ensure resource availability (especially clean toileting stations)
feliway - pheremone
how can urinary health in FIC be promoted?
encourage water intake
slowly introduce dietary modifications
avoid obesity
GAG supplementation
how can encouraging water intake in cats promote urinary health?
dilute inflammatory mediators / noxious substances in urine
what dietary changes can be made to promote urinary health?
wet diets
urinary diets - often contain anti-anxiety compounds
why may GAG supplementation help to promote urinary health?
reduced GAG in FIC cats which means they have lower protection against noxious substances in urine
supplementation can help
when are antispasmodics often used?
post obstruction
what is the role of Prazosin?
alpha1 blocker which relaxes smooth muscle
what is the downside of Prazosin?
may cause hypotension due to smooth muscle relaxation
what is the effect of Dantrolene?
skeletal muscle relaxant - acts on external urethral sphincter
what are other FIC therapies?
owner education
behavioral consultation
psychoactive medications
what must be done before using behavioral / psychoactive therapies for FIC treatment?
seek refurral or advice
what is urinary incontinence?
loss of normal, voluntary control of micturition
what is involved in normal control of micturition?
local sensory reflexes and conscious control - micturition centre in brainstem will initiate relaxation of urethral sphincter and contraction of bladder leading to conscious voiding
what is neurogenic incontinence?
incontinence due to damage to nerves
what are the 2 types of neurogenic incontinence?
upper motor neurone lesion
lower motor neurone lesion
what nerves are damaged in neurogenic incontinence caused by damage to upper motor neurones?
some in brain or spinal cord
what nerves are damaged in neurogenic incontinence caused by damage to lower motor neurones?
peripheral
what is the bladder like in a patient with an upper motor neuron lesion?
spastic and difficult to express
what is the bladder like in a patient with an lower motor neuron lesion?
flaccid
easy to express
what sort of incontinence is common in animals with neurogenic incontinence?
overflow - unable to void bladder so it becomes too full and urine leaks out
what are the 3 types of non-neurogenic incontinence?
urethral sphincter mechanism incompetence
anatomical defects
urge incontinence
dyssynergia
what causes urethral sphincter mechanism incompetence?
failure of normal sphincter function
when do animals with urethral sphincter mechanism incompetence normally leak?
during recumbancy
what is an example of an anatomical defect which causes incontinence?
ectopic ureters
what are ectopic ureters?
ureter voids directly into urethra leading to frequent dribbling and risk of ascending infection
what causes urge incontinence?
instability of detrusor muscle due to bladder disease / irritation of bladder
what is dyssynergia?
failure of coordination of bladder contraction with urethral relaxation
what is the most common cause of non-neurogenic incontinence in dogs?
urethral sphincter mechanism incompetance
in what dogs is USMI more common?
larger breed, spayed bitches
within what timeframe does USMI often occur/
within a few years of neutering
what are the causes of USMI?
multifactorial -
intra-pelvic bladder
neutering
obesity
why may neutering be associated with USMI?
increased collagen to muscle ration in pelvic floor composition
oestrogen deficiency
what is the treatment for USMI?
tighten urethral sphincter
what methods may be used to tighten the urethral sphincter in USMI cases?
alpha-agonists
oestrogens
urethral cuffs
surgical repositioning of bladder
why are alpha agonists used to treat USMI?
sympathomimetic - alpha adrenergic receptors at sphincter - drugs cause sphincter to contract
what alpha agonists are often given to treat USMI?
Phenylpropanolamine (PPA)
what drugs are given alongside PPA in the treatment of USMI?
oestrogens - enhance effect
how do urethral cuffs treat USMI?
artificial urethral sphincter placed over normal urethral sphincter to enhance effect
how does surgical repositioning of the bladder treat USMI?
bladder is moved back into abdomen from pelvis - this means that when the dog is in lateral recumbancy the weight of the body wall falls on the bladder neck and urethra (aiding sphincter).
where does weight of the body wall, when in lateral recumbancy, fall in patients with USMI?
all onto bladder and none onto bladder neck and urethra as it is within bony cage of pelvis - causes leaking of urine
what are the management considerations for neurogenic incontinence?
treat neurological disease
express bladder
avoid catheterisation - risk of ascending infection
how may anatomic incontinence be treated?
laser to reposition ureteric entry into bladder
surgical re-implantation of ureter into bladder
what must be maintained in all cases of incontinence to prevent ascending infection?
peri-vulval / preputial hygiene
